This area is only available to WorkCompResearch subscribers. WCR offers the most advanced Compliance and Regulatory Research System available.

Already a member? Log-in

Join Today for Immediate Access!


Sign Up


Home| Forms| Legal Library| Compliance| Calculators| State Comparisons| Reference Desk| What's New| Roundtable
Pre-select A State ↓ (Optional)   Current State: None   (← what's this?)

West Virginia Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
If you do not have Adobe Acrobat Reader, you may download it here for free. Download Adobe Here

All of these forms may now be auto-populated from your claims software program! Click here to learn about FlashForm SSL.


Form

Description

OIC-WC-2.pdf Employers' Report of Occupational Injury or Disease
OIC-WC-1.pdf Employees' and Physicians' Report of Occupational Injury or Disease
OIC-WC-1HL.pdf Employees' and Physicians' Report of Occupational Hearing Loss
OIC-WC-1OP.pdf Employees' Report of Occupational Pneumoconiosis
OIC-WC-20P.pdf Employer's Report of Occupational Pneumoconiosis
OIC-WC-30P.pdf Physician's Report of Occupational Pneumoconiosis - Includes ILO Form
OIC-WC-201.pdf Application for Fatal Dependents' Benefits
OIC-WC-202.pdf Application for 104 Weeks Dependents' Benefits
claims-allocation-information.pdf Notification Regarding Claims Allocation
wc_complaint_form.pdf Workers' Compensation Complaint Form
exemption-application.pdf Application for Exemption from WV Workers' Compensation Coverage
microfiche.pdf Request for File Record Copies
citizen_report.pdf Suspected Insurance Fraud Citizen Reporting Form
fraud-company-contact-form.pdf Insurance Company Fraud Contact Form
fraud_uniform_form.pdf Uniform Suspected Insurance Fraud Reporting
occ-lung-exam.pdf Carrier's Request for Occupational Lung Center Examination
rsr1.pdf Request for Settlement Review
complaint-form.pdf Workers' Self-Insurance Compensation Complaint Form
term-cov.pdf Termination of Coverage
travel-expense-notice.pdf Payment for Travel Expenses Notice
UninsuredFundApplication.pdf Employee's Report of Occupational Injury and Proof of Employment
Direct-Deposit-Form.pdf Workers Compensation Direct Deposit Form
Notice.pdf POSTER - Generic Notice to Employees poster.
WVBrochure.pdf Brochure - Understanding the West Virginia Workers' Compensation Claims Process
Low_Back_Examination.pdf Low Back Examination
Perm_Tot_Dia_Rev.pdf Carrier/Self-Insured/TPA Request for Permanent Total Disability Review
origxray.pdf Request for Original X-Rays
xrayrequest.pdf Request for X Rays